dr graham gulbransen - gp cmegpcme.co.nz/pdf/2017 south/sat_room2_1400...case history, 2005...

Dr Graham GulbransenGeneral Practitioner

Kingsland Family Health Centre

Auckland

14:00 - 14:55 WS #114: Medicinal Cannabis for GPs

15:05 - 16:00 WS #125: Medicinal Cannabis for GPs (Repeated)

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Case History, 2005 presentation

• Science writer Professor Stephen Jay Gould, who was treated for a mesothelioma.

• I had surgery, followed by a month of radiation, chemotherapy, more surgery, and a subsequent year of additional chemotherapy. I found that I could control the less severe nausea of radiation by conventional medicines. But when I started intravenous chemotherapy (Adriamycin), absolutely nothing in the available arsenal of antiemetics worked at all. I was miserable and came to dread the frequent treatments with an almost perverse intensity.

• [Smoking] marihuana worked like a charm. I disliked the "side effect" of mental blurring (the "main effect" for recreational users), but the sheer bliss of not experiencing nausea -and then not having to fear it for all the days intervening between treatments -was the greatest boost I received in all my year of treatment, and surely had a most important effect upon my eventual cure. (Brit Med Assn, 1997, p. 90)

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Cannabis as Medicine in Australia

Presented at

International Medicine in Addiction Conference, Sydney 26/3/17

Prof Nicholas Lintzeris MBBS, PhD, FAChAM

Director D&A Services, SESLHD

University of Sydney, Division Addiction Medicine

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Hemp Expo

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UIC

Assoc Prof

David Caldicott

Canberra

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‘…almost everybody knows

that cannabis is either essentially harmless

or else necessarily toxic.

Yet, like most arguments,

the truth is between these extremes, depending on

the ages of use,

and frequency and chronicity of use.’

Richard P Mattick,

Drug and Alcohol Review,

July 2017

You may find this presentation

challenging…

1. Is it safe?

2. Is it legal?

3. Is it snake oil?

4. Why haven’t we been taught about

ECS?

5. Should GPs be recommending herbs?

6. How do GPs recommend/prescribe?

7. Remember medicinal cannabis is here

now!

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Summary

• Recreational vs medicinal cannabis

• Case histories

• Mechanism of Action: EndoCannabinoid

System ~ Biological Plausibility

• Medicinal uses

• How to prescribe

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Cannabis plant

• Thousands of strains – like tomatoes!

• THC & CBD main active compounds

• Continuum from

– THC dominant

– Balanced

– CBD dominant

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>100 cannabinoids in cannabis plant. Most non-psychoactive.

Each cannabinoid has its own pharmacological actions and therapeutic potential.

Plus … terpenes

“Entourage” effects: whole plant vs single molecules

Phytocannabinoids

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Definitions

• Recreational

• Therapeutic

• Medicinal

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Potency of NSW police seized cannabis: high THC and low

CBDSwift et al PLoS One 2013

THC THC-A THC TOTAL0

5

10

15

20

25

30

35

40

%CONTENT

%CONTENT

CBD CBD-A CBD Total0

5

10

15

20

25

30

35

40 85% of samples contained <0.1% CBD-tot

Average THC content = 15%

THC: psychoactive, sedation, analgesia, antiemesis, antispasmodic

CBD: anxiolytic, antipsychotic, anticonvulsant, protective against memory loss

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SativexEach spray THC 2.7mg, CBD 2.5mg, ethanol, peppermint oil

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• MULTIPLE SCLEROSIS

• Left hemiparesis

• Disease modifying therapy: tecfidera

• Muscle spasms: baclofen inadequate.

• Prescribe Sativex with neurologist

recommendation.

Prescription pathways at the end of this

presentation.

Peter 58 (MS)

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• Terminal pancreatic cancer

• Palliative care; chemotherapy nothing more to offer

• Smoked cannabis during chemo

– Less nausea

– Better appetite, but lost weight

– Less pain

– But – hated smoking, illegal

• Sativex approved – easy to take, control dose, no choking, eases abdo discomfort, huge appetite stimulant, regained weight!

Lynda 67 (Palliative care)

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Barbara 35 (Chronic pain)• Severe endometriosis, 18 surgeries, full pelvic

clearance

• Chronic pain, central sensitisation disorder

• Past misuse of prescription and illicit drugs to

manage chronic endometriosis pain

(pseudoaddiction)

• Was using cannabis most evenings for

analgesia.

• Sativex approved. 1-2 sprays per week effective.

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• Autism spectrum disorder, global development

delay, blind, epilepsy with uncontrolled

prolonged seizures about twice a week.

Anticonvulsants ineffective with intolerable

adverse effects.

• Hemp extract drops taken with unbroken sleep

for the first time in his life and calmer during the

day! Rapid recovery from seizures.

Nick 20 (Knobloch Syndrome)

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Jo 61 (MSA)• Multiple systems atrophy, cerebellar type

• (chronic progressive debilitating neurological

condition)

• Quadraparesis, confined to bed, dystonia,

muscle spasms, contractures, depressed

• Clonazepam, levodopa/benserazide:

minimal relief

• Sativex approved, difficult to use, short trial

ineffective.

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Eddie 30 (Chronic pain)• Unexplained chronic facial pain 10 years

• Several surgeries without benefit

• 3 weeks after taking 10 drops of hemp extract

tid:

– Reduced oxycodone from 70mg 40mg daily

– Stopped gabapentin 600mg daily

– Stopped nitrazepam 10mg nocte for sleep

• Continues hemp extract, feels hope for the first

time.

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President and founding member of The Society of Cannabis Clinicians

Introduction

Jeffrey Y. Hergenrather, MD

General practice physician

Solo private practice

Cannabis consultations since 1997

Sebastopol, California

I have no financial relationships to disclose.

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Jeffrey Y. Hergenrather MDCannabis consultantSebastopol, CA, USA

United In CompassionMelbourne Convention & Exhibition Centre

June 23 - 25, 2017

Developing the Treatment Plan

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Conditions in Clinical PracticeRank order - Hergenrather 2017

• Pain (acute pain, chronic inflammatory, neuropathic)• Mental disorders (all kinds)• Cancers• Gastrointestinal disorders• Insomnia• Migraine headaches• Harm reduction, alternative to opioids . . . • Spastic disorders• Autoimmune disorders• Neurodegenerative disorders• Glaucoma• Skin diseases• Epilepsy, Autism, Tourettes, ADD, Dystonia, Dementia

• AIDS and other infections

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Have you any patients

who are ‘stuck’?

Conventional medicines

just not working?

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SativexEach spray THC 2.7mg, CBD 2.5mg, ethanol, peppermint oil

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What is Sativex®?Sativex® is a cannabis-based product classified

as a Schedule 2, Part 1 (Class B1) controlled

drug product under the Misuse of Drugs Act

1975.

Sativex® is an oromucosal (mouth) spray

administering a metered, actuated dose

containing the cannabis extracts delta-9-

tetrahydrocannabinol (THC) (2.7 mg/spray)

and cannabidiol (CBD) (2.5 mg/spray)

[+ traces of terpenes and other cannabinoids].

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What is Sativex®

approved for?

• In New Zealand Sativex® is approved for

use as an add-on treatment for symptom

improvement in patients with moderate to

severe spasticity due to Multiple Sclerosis

who have not responded adequately to

other anti-spasticity medication and who

demonstrate clinically significant

improvement in spasticity related

symptoms during an initial trial of therapy.

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Sativex dosing

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Five Pathways to medicinal cannabis

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1. Restriction on the Supply of Sativex—Approval to Prescribe, Supply

and Administer (Approval No. 2016/AP305)

• MS: spasms not managed by conventional

medicine

• Medical practitioners… acting on the written

recommendation… of a Neurologist may

prescribe Sativex

• The prescriber is required to state multiple

sclerosis & Neurologist name on the

prescription form.

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1. Restriction on the Supply of Sativex—Approval to Prescribe, Supply

and Administer (Approval No. 2016/AP305)

• Medical practitioners with a vocational scope of practice of Internal Medicine (specialising in neurology), registered with the Medical Council of New Zealand under the Health Practitioners Competence Assurance Act 2003, for the treatment of multiple sclerosis; or

• any other medical practitioner registered with the Medical Council of New Zealand when acting on the written recommendation of one of the medical practitioners with the vocational scope described above, for the condition specified. The name of the recommending medical practitioner with the appropriate vocational scope must be endorsed on the prescription form.

• The prescriber is required to state the condition being treated (ie “multiple sclerosis”) on the prescription form.

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2. Sativex ‘unapproved use’

• Form 2

• 6 pages

• GP & Specialist signatures

• Process time 1 – 4 weeks.

• SPECIAL AUTHORITY FORM – My proposal for an efficient approval system!!!

• However, as GPs we know that evidence based medicine doesn’t work for everyone, we work in ‘zones of therapeutic uncertainty’

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Form 2

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Form 2

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3. Application for Ministerial approval to

prescribe a pharmaceutical grade cannabis-

based product without consent for

distribution in New Zealand

under Regulation 22 of the Misuse of Drugs

Regulations 1977

Please note that the Government does not

support the use of unprocessed or

partially processed cannabis leaf or flower

preparations for medicinal use.

http://www.health.govt.nz/our-work/regulation-health-and-disability-

system/medicines-control/prescribing-cannabis-based-products

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a.application from an appropriate specialist

b.a manufacturer has demonstrated a commitment to the development of the

product as a pharmaceutical or

c.the product has been prepared pharmaceutically and the characteristics and

formulation are clearly described and defined

d.the product has completed animal studies demonstrating proof of concept and

potential clinical benefit

e.the product is undergoing an appropriately designed Phase II clinical study or

f.the product has completed clinical trials and is marketed overseas but is not

approved for distribution in New Zealand

g.the product is available for use

h.the following are met where relevant:

i. evidence that there will be close follow up of patient by a prescriber

ii. evidence that a wide range of conventional treatments have been trialled

and symptoms are still poorly controlled

iii. condition is an approved condition for use or

iv. condition is one for which there is some evidence of efficacy, preferably in

clinical trials

v. Ministry clinicians assess application is appropriate if for non-approved use

vi. no history of abuse or diversion of controlled drugs

vii. the patient has no known contraindication to the use of the product

viii. initial approvals usually for 6 months

ix. baseline clinical indicators generally required and evidence of improvement

before a new approval is given.

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4. Alternatives to Sativex

‘In practical terms the changes mean CBD

would be able to be prescribed by a doctor to

their patient and supplied in a manner similar to

other prescription medicine.’

Peter Dunne, Associate Minister of Health, 2/6/17.

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5. Compassionate Cannabis

• Medical Cannabis Awareness NZ,

http://mcawarenessnz.org/

• Patients could go to

Auckland Patients Group on

and write a post introducing themselves, their

condition and request support.

• Several licenced NZ hemp farms may have

animal remedies eg for stressed dogs.

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Hikurangi Hemp, coming soon…

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Varieties of Cannabinoids

Endocannabinoids PhytocannabinoidsSynthetic

cannabinoids

In our brain and body In plants From the lab

Anandamide (AEA), 2-AG, Noladin ether

etc.

THC, CBD, CBG, CBDV, THCV, CBC, CBN, THCVA

etc.

Nabilone, HU-210, AB-PINACA, JWH-018,

Includes K2, Kronik etc

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Biological Plausibility: ECS• There’s a reason cannabis works:

– The Endocannabinoid System• ‘Neuro-immuno homeostasis signalling system’

• Present in all vertebrates, in most animals from sea squirts to humans

• Cannabinoid receptors are present throughout the body, embedded in cell membranes, and are believed to be more numerous than any other receptor system.

Viola Brugnatelli - Neuroscientist

Hemp Expo Sydney May 2017 & https://naturegoingsmart.com/understanding-endocannabinoid-system/

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Endocannabinoid System - ECS Homeostasis

• CB1 receptors:

– Brain: cortex, basal ganglia,

hippocampus, cerebellum

– Modulate: memory, mood,

executive function, cognition,

analgesia, movement

– GI: appetite, lipolysis

– Respiratory

• CB2 receptors

– Immune system: regulate

inflammation, neuropathic pain

• CB3 & other receptors under

investigation

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Slide by Viola Brugnatelli

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In each tissue, the cannabinoid system performs different tasks, but the goal is

always the same: homeostasis.

At the site of an injury, for example, cannabinoids can be found

• decreasing the release of activators and sensitizers from the injured tissue

• stabilizing the nerve cell to prevent excessive firing

• calming nearby immune cells to prevent release of pro‐inflammatory

substances

Cannabinoid receptors are present throughout the body, embedded in cell

membranes, and are believed to be more numerous than any other receptor

system.

Endocannabinoids are synthesised on‐demand from cell membrane arachidonic acid

derivatives, have a local effect and short half‐life before being degraded by the enzymes

fatty acid amide hydrolase (FAAH) and monoacylglycerol lipase (MAGL)

Modified from https://naturegoingsmart.com/understanding-endocannabinoid-system/

by Viola Brugnatelli.

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Cannabinoid

retrograde

neurotransmission

Viola Brugnatelli, neuroscientist,

https://naturegoingsmart.com/understanding

-endocannabinoid-system/ 2017

Stahl’s Essential

Psychopharmacology, 2008,

p56

Cannabinoids regulate neurotransmission

• Pain

• Epilepsy

• Anxiety, PTSD

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Ca2+

channel

Na+, K+

channels

Glutamate

Presynaptic cellaction potential

Postsynaptic cell

NMDA mGLU NMDA

• Ca2+ influx into post-synaptic cell stimulates the synthesis and release of 2-AG.

• 2-AG diffuses retrograde to presynaptic CB1, which closes pre-synaptic Ca2+

channels and stops vesicle release.

Ca2+

channel AMPA

(Wilson & Nicholl, 2002)

Depolarization-Induced Suppression of Excitation

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Ca2+

channel

Na+, K+

channels

GABA

Presynaptic cellaction potential

Postsynaptic cell

GABAA

• Ca2+ influx into post-synaptic cell stimulates the synthesis and release of 2-AG.

• 2-AG diffuses retrograde to presynaptic CB1, which closes pre-synaptic Ca2+

channels and stops vesicle release

Ca2+

channel

Depolarization-Induced Suppression of Inhibition

GABAB

(Wilson & Nicholl, 2002)

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Cannabinoids play immunomodulatory role

Abundant evidence indicates that cannabinoids modulate immune responses. Activation effectively down-regulates immune activity without compromising efficacy of the immune system.

Δ⁹-THC attenuates allogenic host-versus-graft response indicating possible role in transplant rejection.

Nagarkatti et al 2015In a Simian monkey study chronic Δ-9-THC administration prior to and during simian immunodeficiency virus (SIV) infection ameliorates disease progression, attenuates viral load and tissue inflammation, significantly reducing morbidity and mortality of

SIV-infected macaques. Winsauer et al, 2011

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Evidence of Benefit

• 2017 National Academies of Science, Engineering, Medicine, USA reviewed 10,700 clinical studies

• Few high quality RCTs available:

– Prohibition restricts supply and standardisation of cannabis

– Cannabis plant has hundreds of compounds to study separately and individually, different ratios

– Plants cant be patented, reduces funding sources

• EBM vs Personalised Medicine: GPs know RCTs are a guide but not real-world, we personalise Rx

• Neuroscientists have huge research data-base

• Patients’ experience of illicit cannabis useful guide.

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Systematic review Cannabinoids Whiting et al JAMA June 2015

Condition # studies Strength of

evidence

Conclusion

Nausea & vomiting 3 RCTs Low THC or THC/CBD >

placebo

Weight gain in HIV/AIDS 1 RCT Low THC > placebo

Spasticity in MS /

paraplegia

14 RCTs Moderate THC/CBD > placebo

Depression 3 RCTs Low Placebo > THC/CBD

Anxiety 1 RCT Low CBD>placebo

Sleep 12 RCTs Low THC/CBD, THC >

Placebo

Psychosis 1 RCT Low CBD = amisulpiride

Tourette Syndrome 1 RCT Low THC > placebo

Glaucoma 1 RCT Low THC=CBD=placebo

Epilepsy Not

completed

N/A CBD

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Cannabinoids in chronic painSystematic review: Whiting et al JAMA June 2015

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Compared to other medicines we use to treat

pain

Grant I, AMA Journal Ethics. 2013

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Targeting cannabinoids for people with

CNCP

• Pain, substance use, mood and sleep disorders often co-occur, and individually difficult to address

• Childhood trauma is a common link

• Role of cannabinoids for this population?– Cannabinoids target the ‘distress’ of pain > pain ‘severity’

– Cannabinoids involved with mood, sleep, substance use

– Safer profile than many other medicines used by pain patients

• Could cannabinoids be a useful strategy in addressing ‘high risk’ medication in pain patients - or will they contribute to the problem?– All CB RCTs for pain to date have excluded ‘addiction

comorbidities’

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Medical cannabis & opioid related

deaths

Bachhuber et al 2014. Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010. JAMA Int Med 174:1668-73.

• “Medical cannabis laws are associated with significantly lower state-level opioid overdose mortality rates. Further investigation is required to …”

Review of opioid-sparing role of cannabinoids – animal and clinical studies: suggestive but not conclusive

(Nielsen et al Neuropsychopharmacologyaccepted)

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CBs for cannabis withdrawal

• Nabiximols (Sativex) effective in treating cannabis withdrawal (Allsop JAMA Psychiatry 2015)

• Similar positive findings with synthetic THC (dronabinol, nabilone)

• BUT … withdrawal alone rarely results in better long term outcomes …

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Cannabinoid agonist substitution

treatment • Nabiximols vs placebo RCT underway in NSW

(49% THC, 49% CBD, 1% other CBs)

• University Sydney, NHMRC funded

• SESLHD, WSLHD, HNELHD

• Target n=142, ~100 enrolled thus far …

• Interventions:

• Weekly review & medication supply

• Nabiximols dose: up to 32 sprays / day (~80mg THC /

CBD)

• Manualised CBT both groups

• 1° Outcomes: cannabis use, safety, cost

effectiveness

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Cannabinoids for other addictions:

‘exit drug’• Alcohol

– CBD (and other CBs) for alcohol withdrawal, relapse

prevention, cravings

• Opioids

– CBs (THC) for opioid withdrawal

– Opioid sparing in pain management

• Amphetamines

– Promising animal research re: CBD

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CAMS-16: NZ Health SurveyReason for use (n=1624) 2012/13 (n=13,009)

Aussie

• One third

‘pain’

• One third

‘mental

health

conditions

’

• One third

‘other’

NZ

• 11% used cannabis in past

year

• 5% used cannabis

medicinally

• Of those

• 40% for pain

• 27% for anxiety

• 26% for depression

• 11% for nausea

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CAMS:16 (preliminary data

only)

• Male 68%, Mean age: 38; 62% employed / student

• Using CAM for 10 yrs (mean)– ~ half using cannabis for other reasons before ‘medical’ use

– ~ half not using cannabis (2/3rds any prior use, 1/3rd never used)

• Median levels of use: 20/28 days; 3gm/day, $72 / week

• Source:– Recreational dealer: 42%; Friends/family 33%; grow own 13%;

medical cannabis supplier 10%

• Route:– Smoked 63% (“Bong”/ pipe 43%; “joint” 19%; “dabbing” 1%)

– Vaporiser: 14%

– Oral: 21%

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Potency of NSW police seized cannabis: high THC and low

CBDSwift et al PLoS One 2013

THC THC-A THC TOTAL0

5

10

15

20

25

30

35

40

%CONTENT

%CONTENT

CBD CBD-A CBD Total0

5

10

15

20

25

30

35

40 85% of samples contained <0.1% CBD-tot

Average THC content = 15%

THC: psychoactive, sedation, analgesia, antiemesis, antispasmodic

CBD: not psychoactive, anxiolytic, antipsychotic, anticonvulsant, protective against memory loss

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Drug harms in the

UK: a multicriteria

decision analysis

Prof David J Nutt. 2010

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Potential harms / AEs of cannabis (high THC)

• Cognition & performance– Sedation and mild cognitive impairments in attention, memory,

learning, psychomotor functions. Most effects reversible with abstinence, although may persist in heavy adolescent users

– Intoxication related injuries (e.g. driving, falls)

• Mental health– Increased risk of psychoses OR = 2.09 (95%CI 1.54 to 2.84) &

linked to genetic predisposition

– Adolescent cannabis use associated with increased anxiety

• Dependence: estimated at 1 to 10% illicit users

• Physical effects– Hypotension, tachycardia, dizziness, dry mouth, respiratory

• Drug-drug interactions: CBD (THC) is CYP450 inhibitor

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Sativex Adverse EffectsSee New Zealand Data Sheet for full list

• Very common > 10%: dizziness & fatigue during titration

• Common: 1 – 10%: appetite changes, depression,

disorientation, dissociation, euphoria, asthenia, feeling

drunk, malaise, blurred vision, vertigo, constipation,

diarrhoea, dry mouth, mouth ulcers, nausea, vomiting

• Uncommon: 0.1 – 1%: hallucination, paranoia, suicidal

thoughts, syncope, tachycardia, abdo pain etc

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Sativex Drug-Drug Interactions (DDIs)

• Unlikely with usual doses of Sativex

• Cytochrome P450 metabolism,

• CYP3A4 inhibitors may increase THC levels• Ketoconazole, itraconazole, ritonavir, clarithromycin

• CYP3A4 inducers may reduce THC levels

– Rifampicin, carbamazepine, phenytoin, St Johns Wort

• Care with sedatives, alcohol

• Anti-spasticity agents may increase risk of falls.

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>100 cannabinoids in cannabis plant. Most non-psychoactive.

Each cannabinoid has its own pharmacological actions and therapeutic potential.

Plus … terpenes

“Entourage” effects: whole plant vs single molecules

Phytocannabinoids

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Cannabidiol (CBD)

• A non-intoxicating cannabinoid– Anticonvulsant effects

– Anxiolytic, antipsychotic

– Neuroprotective: ?dementia

– Analgesia: THC+CBD > THC or CBD alone; synergistic

• Hepatic metabolism: – CYP 3A4, 2D9 inhibition: ?clinically relevant

• Doses: – ?200-1200mg oral / day prescribed

– 10-50mg oral / day OTC for ‘wellness’

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TerpenesFrom Epilepsy Action Australia

www.epilepsy.org.au

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Using Plant

Cannabis

• Higher bioavailability inhaled– 10-35% inhaled

– 5-15% oral (hepatic CYP 2C8/9/19)

• Peak effects: – Inhaled:10-90 minutes after use

– Oral: 60- 240 minutes after use

• Vaporising: similar to ‘e-cigarettes’– heats cannabis at lower temperature

– fewer ‘toxins’, higher bioavailability

– no side stream smoke (fewer concerns re: passive smoking)

– TGA-compliant devices: Volcano, Mighty Medic

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Vaporisers: The Hemp Store

www.hempstore.co.nz

Arizer Air handheld

Vaporite digital desktop

Focus handheld

Herb chamber

mouthpiece

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Acknowledgements

• Presenters at the United in Compassion

Australian Medicinal Cannabis Course &

Symposium, Melbourne June 2017

• Assoc Prof David Caldicott

• Prof Nick Lintzeris

• Dr Jeffrey Hergenrather

• Dr Viola Brugnatelli

• Justin Sinclair

~NGA MIHI NUI~

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